Windrush Day 2021: The early years of the NHS

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‘Those who are happiest are those who do the most for others’ – Booker T Washington

The National Health Service is famously the largest employer in Europe. Equally importantly, it relies on a wide range of occupations, an estimated 350, from over 200 nationalities, to keep the system functioning. Approximately 170,000 of NHS staff report non-British nationality, over 100,000 of whom are from non-EU countries. This represents approximately 1 in 7 of all NHS employees, with a large proportion working in London and the Midlands. The roots of this critical component of the NHS workforce grow in the soil of the establishment of the NHS. Understanding the origin story helps explain the demographics, and the challenges, of the current workforce.

There were less than two weeks between the docking of the Empire Windrush at Tilbury on 22^nd June 1948 and the launch of the NHS on 5^th July that same year. The British Nationality Act of 1948  created the status of "citizen of the United Kingdom and Colonies" for people born or naturalised in either the United Kingdom or one of its colonies, and there was a much-required influx of ethnic minority people to help in the reconstruction of post-war Britain. I myself, arriving as a child from Africa in the 1970s had the term ‘Naturalised Alien’ written next to the nationality line in my Nigerian passport.

The NHS dependence on workers from abroad from its very start has made it one of the most diverse workplaces in the UK. Data was not kept about the ethnic origin of the workforce in those early years, but anecdotally, a large number of nurses in the early NHS were of Irish origin. Nursing recruitment was a priority in those early years of the service. In 1948, there were 54,000 nursing vacancies and so from early 1949, the health and labour ministries launched recruitment campaigns from countries which were still under the yoke of British colonialism. Consequently, thousands of nurses arrived in the UK and were deployed especially in metropolitan areas of London and the Midlands and in the so-called ‘Cinderella’ specialties such as mental health and elderly care.

By 1955 there were nursing recruitment programmes across 16 British colonies and former colonies providing a ready supply of staff to the NHS which was not producing enough staff of its own through education. By the end of 1965, there were an estimated 5,000 Jamaican nurses working in British hospitals. It has been estimated that by 1977 overseas recruits represented 12% of the student nurse and midwife population in Britain, of which two-thirds were from the Caribbean.

Doctor recruitment was also a strong focus from early years too. The Willink commission report on medical manpower in 1957 found that 12% of doctors were overseas-trained. In subsequent decades, migration from South East Asia became a core requirement of staffing primary care and hospital posts, such that by 1979, the Royal Commission on the NHS estimated that there were 20,000 NHS doctors (about one-third of the medical workforce) born outside the UK, over half of whom originated from the Indian subcontinent.

By 1958, there were 125,000 people from the Caribbean and 55,000 from India and Pakistan working more widely in the UK. These numbers prompted political regulation of immigration, which has changed back and forth over the years, but always in a manner sensitive to the fluctuating workforce needs of the NHS. This has sometimes been to the detriment of both some donor countries struggling to maintain their services and to the individuals who have restrictions placed on their ability to practice. For example, automatic right of entry was removed by the 1971 Immigration Act, and work permits for training nurses were abolished in 1983, but the anticipated expansion of UK-trained nurse staff fell consistently short. Subsequent easing of restrictions resulted in a situation in the early 2000s when influx exceeded demand, at which point a work permit visa system was introduced to restrict the entry of international medical graduates. Post-Brexit, the current UK government, recognising the potential shortfall of staff from Europe, has announced its decision to remove the restriction on overseas doctors and nurses entering through the Tier 2 visa route.

The history of employment in the NHS is one of being highly reactive to the short-term service needs rather than having a vision for workforce planning. In this context, internationally-trained staff have been regarded as a commodity in a buyer’s market, namely as goods which are plentifully available allowing the consumer to keep prices down. The willingness of those staff to work hard, in the service of their adopted country of residence has been utilised to plug gaps and not be habitually regarded as equal members of staff. The race inequity in the NHS workforce revealed by  serial WRES data reports is rooted in that history of institutional racism, itself planted in a wider society where race discrimination is either denied, trivialised, or colluded with. On this 73^rd anniversary of the NHS and the landing of the Windrush, we all need to take responsibility to act to deliver on racial justice.